Since the dawn of the DRA at the close of 2005, health care observers have predicted a follow-on DRA II. It appears that this prediction will come to pass shortly after the clock strikes midnight on December 31.
In a carefully considered presentation at the Gleacher Center in Chicago on December 2, Shay Pratt, managing director, The Advisory Board, Washington DC, laid out for members the potential impact of the reforms contained in the 2010 Medicare Physician Fee Schedule final rule as well as imaging-specific measures contained in competing health reform bills, both on imaging reimbursement and the freestanding market at large.
“With reform discussions, there is so much going on with imaging in particular that it is a good question to ask: What will happen to future demand and profitability with the current proposals on the table?”
—Shay Pratt, managing director The Advisory Board, Washington, DC
Volume to Grow, Payments to Plummet
Imaging has been a high growth area for the past ten years, though the DRA, the economic downturn, and preauthorization in particular have dampened that growth considerably, Pratt commences. Reform talk aside, The Advisory Board expects outpatient growth to resume in the near term once unemployment rates normalize. MRI is expected to grow from 25.8 million outpatient procedures in 2008 to 33.7 million procedures in 2013, for instance. Outpatient CT procedures are anticipated to increase from 48.3 million in 2008 to 62.3 million in 2013.
Thanks to the 2010 MPFS Final Rule, however, steep declines in reimbursement for freestanding and in-office outpatient imaging can be anticipated. “Across radiology there are a lot of reductions going on,” Pratt says. “There are a couple of things in play here: There are general reductions downward for some RVUs because [CMS is] borrowing from imaging to pay for increases in primary care and other areas; there are malpractice adjustments; and there are other general practice expense changes. But the big story is the change to the equipment utilization rate factor.”
The 2010 MPFS final rule calls for a four-year phase-in of a new 90% equipment utilization rate assumption that will see payment for some codes falling below the HOPPS in the next two years. An ACR impact analysis show a 5% reduction in global payments in 2010 and a 16% reduction in 2013, when the 90% equipment utilization rate assumption is fully implemented.
Much of that decline will be contributed by steep cuts to the technical component. Pratt offers the example of 74160 CT abdomen with contrast. According to the fee schedule, the technical component of this code was $298 in 2009, but the DRA caps the payment at the lesser of the physician fee schedule or the hospital rate, which was $297, so Medicare part B paid the technical component at $1 less. But as the equipment utilization factor is phased in, the technical payment rate drops 13% to $259 in 2010, and 45% in 2013, to $162.
“Eventually you are looking at a huge hit in terms of the technical payment for this procedure,” Pratt notes. “This is a case in which a procedure will be paid less than the hospital rate next year.”
Some procedures will fall below the HOPPS payment rate later than others. Pratt offers the example of MRI Chest Spine w/o contrast: The DRA caps the 2010 technical component at the 2010 HOPPS payment rate of $349 in 2010, but in 2011, the technical component rate falls to $330, $19 below the hospital rate.
“In general by 2011, you will start see the early signs, but by 2012, most codes will be paid less than the hospital rate,” Pratt reports.
Health Reform Bill to the Rescue?
Pratt notes that the two health care reform bills under consideration could mitigate the 90% increase put forth by CMS. The House bill would increase the equipment utilization rate factor to 75% in 2011, while the Senate version offers a more gradual increase in the rate assumption: 65% until 2012; 70% the following year; and 75% in 2014.
“The Senate version also calls for an impact study to make sure there is no detrimental affect on access,” Pratt notes. “The bottom line is that with the reform bill’s passage, the full 90% utilization factor increase won’t be implemented, but there nevertheless will be a reduction in payment for most codes if the 75% factor goes into effect.”